A News Publication Linking CareFirst and CareFirst BlueChoice with Participating Physicians, Providers and Institutions

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1 A News Publication Linking CareFirst and CareFirst BlueChoice with Participating Physicians, Providers and Institutions CareFirst and CareFirst BlueChoice are always looking for ways to speed up and simplify the claims filing and payment process for participating physicians and health care providers. One way to do that is through enhanced use of EDI services. CareFirst has teamed with RealMed, a revenue cycle management and clearinghouse solution to provide enhanced electronic capabilities to participating CareFirst physicians. Currently, RealMed users can submit single claims or unlimitedsize batch claims to CareFirst through a Web-based, HIPAA compliant system that expedites remittance and payment. And RealMed can update claim status each day on most pending claims with detailed information that helps identify problem claims or categories of claims. But administrative efficiency improvements will take an even larger step forward in the months to come as RealMed introduces and rolls out a number of capabilities specifically for CareFirst network physicians. While these capabilities may not yet be immediately available over all claims platforms or for all categories of health care providers, RealMed and CareFirst are committed to expanding their availability. Here are some of the ways that RealMed will be able to help your practice work better with CareFirst: Verify Insurance Coverage/Perform Eligibility Checks in Advance When eligibility information is correct, your practice can accurately bill both the payer and the patient, therefore eliminating up to 60 percent of the causes of claim denials. You will increase your cash flow and decrease days in accounts receivable. With RealMed, you can confirm patient eligibility either individually or through unlimited-size batch files. This confirmation can even take place prior to the patient s appointment, and will highlight potential problems for your review and correction. All information is displayed in a consistent format regardless of the payer, which increases your operating efficiency. Manage Payer Edits/Errors Even the best front-end practices cannot put an end to all claim denials. However, RealMed can (continued page 2) Note: All references to CareFirst in this publication refer to CareFirst BlueCross BlueShield. All references to CareFirst BlueChoice refer to CareFirst BlueChoice, Inc.

2 2 BLUELINK July/August 2009 Vol. 11, Issue 4 Visit us at help save valuable time and resources with the reworking/resubmittal process. RealMed instantly applies the edits providers designate to claims before they go to the payer, including basic content validation, CCI, HIPAA, clearinghouse, payer-specific and custom edits. Easily understandable error messages are instantly returned, which highlight the problem with the claim, and offer a clear explanation of what is wrong and how to fix it. With RealMed, corrected claims can be resubmitted with only a few clicks of the mouse to greatly reduce follow-up calls and other work typically required to fix denied claims. Claims Attachments (Claims Processed on Facets Platform Initially) RealMed allows you to securely exchange claim attachments, documentation, and correspondence with CareFirst. Upon submission of a batch of electronic claims, RealMed will identify claims requiring attachments upfront. You will be able to upload the necessary documentation via RealMed secure Web site for electronic submission. RealMed s process includes end-to-end claim tracking, thereby eliminating the need for phone calls by your staff to validate CareFirst s receipt of your documentation. Status Management RealMed updates claim status each day on most pending claims, and allows providers to sort them by status category, payer, date range, age, claim number and provider, so that you can see problem claims or categories of claims. This shifts the use of your staff s time from seeking status information to actually using it and taking action accordingly. Electronic Funds Transfer (Claims Processed on Facets Platform Initially) CareFirst is planning to offer physician practices and ancillary providers the ability to receive payments via Electronic Funds Transfer (EFT). With EFT, payments can be seven days faster than with paper checks. Direct deposits are more secure and reduce the amount of required paperwork. EFT also improves the practice s financial results by shortening the number of days outstanding. CareFirst expects enrollment in the EFT service will be available via RealMed later this year. It is important to note that this capability will not be available at the institutional level. RealMed, received number one ranking in the KLAS 2009 Managing the Claim and Getting Paid: Ambulatory Clearinghouse Services Report. RealMed achieved this recognition in its first year of inclusion in KLAS. RealMed is ranked first of fourteen EDI clearinghouses in the KLAS report. For questions or to discuss how RealMed can help your practice, contact RealMed at You may also send an to carefirst@realmed.com or visit The American Academy of Pediatrics (AAP) recently published changes to its recommendations for Synagis prophylaxis for Respiratory Syncytial Virus (RSV) in the 2009 edition of the Red Book, the report of the AAP s Committee on Infectious Diseases. The major changes are to the 32 to 35 week gestational age category. The recommendations previously required an infant to be younger than 6 months old at the start of the RSV season and have two of five listed risk factors. For 2009 to 2010, the AAP has changed the number of risk factors applicable to the 32 to 35 week gestation group from five to two, and requires only one of those two risk factors to be present for the infant to fulfill the risk factor requirement. The two remaining risk factors are: The infant attends child care There are siblings less than five years of age living in the household If an infant without hemodynamically significant congenital heart disease or chronic lung disease of prematurity in the 32 to 35 week gestational age group has at least one of the two risk factors, the child may receive a maximum of three doses of Synagis, given at monthly intervals during the first 90 days of life only. The AAP s recommendations remain unchanged for children with congenital heart disease, chronic lung disease of prematurity and birth before 32 weeks gestation. Based on results of several years of state-by-state RSV surveillance by the CDC (accessed on the internet at com/nrevss/main.asp), CareFirst uses November 1 as the start of the RSV season, although the season usually begins in this region after mid- November. Pediatricians and other providers are encouraged to consult the Web site for information about the RSV season. For the full text of AAP s recommendations for Synagis prophylaxis, please refer to the Red Book or to AAP s Web site.

3 July/August 2009 Vol. 11, Issue 4 BLUELINK 3 To respond to your questions in a more timely manner, we have implemented several enhancements to our EDI (Electronic Data Interchange) Hotline service. As of June 22, 2009, the EDI Hotline is now re-directed to our centralized Help Desk operation. What does this mean to providers? Your call will be answered by a live agent Assignment of a Magic Ticket number to assist in tracking resolutions/future inquiries regarding same issue Quicker response New toll-free number * To better assist you, please be prepared to identify the issue that prompted your call, such as: 835 ERA s/enrollment NPI 837 claim status for NCOF (no claim on file) or front end rejections from CareFirst The existing hotline number, , will remain active until Sept. 22, 2009, in order to facilitate this change. Send supplementary information related to your Help Desk ticket to hippa.partner@carefirst.com. Reference the Magic Ticket number in the subject line of the . Thank you for your cooperation as we implement this transition. Please forward this to your billing department and other appropriate staff. *If you are inquiring about claim status do not call the toll-free telephone number. Please continue to use BlueLine, FirstLine or CareFirst Direct.

4 4 BLUELINK July/August 2009 Vol. 11, Issue 4 Visit us at *Note: Current Procedural Terminology (CPT ) codes and descriptions only are copyright of the 1966 American Medical Association. All rights reserved.

5 July/August 2009 Vol. 11, Issue 4 BLUELINK 5 Our Health Care Policy department continually reviews medical policies and operating procedures as new, evidence-based information becomes available regarding advances in new or emerging technologies, as well as current technologies, procedures and services. The table below is a guide designed to provide updates on any changes to existing or new local policies and procedures during our review process. Each local policy or procedure listed includes a brief description of its status, select reporting instructions and effective dates. Policies for non-local accounts, such as NASCO and FEP, may differ from our local determinations. Please verify member eligibility and benefits prior to rendering services via BlueLine, FirstLine or CareFirst Direct.

6 6 BLUELINK July/August 2009 Vol. 11, Issue 4 Visit us at

7 July/August 2009 Vol. 11, Issue 4 BLUELINK 7 *Note: Current Procedural Terminology (CPT ) codes and descriptions only are copyright of the 1966 American Medical Association. All rights reserved.

8 8 BLUELINK July/August 2009 Vol. 11, Issue 4 Visit us at CareFirst and CareFirst BlueChoice offer half-day seminars and webinars designed to familiarize professional and institutional providers and office staff with CareFirst and CareFirst BlueChoice policy, provider-oriented procedures and tools. The types of seminars and webinars are listed below accompanied by a brief description and its identification code to assist in selecting the presentations that best meet your needs.

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10 10 BLUELINK July/August 2009 Vol. 11, Issue 4 Visit us at The following prescription drugs require prior authorization for new prescriptions covered under the CareFirst and CareFirst BlueChoice prescription drug plan: Cimzia - requires prior use of both Enbrel and Humira Simponi - requires prior use of both Enbrel and Humira Nuvigil - requires prior authorization The following drugs now have generic equivalents. The generics are available as a tier 1 and the brandname drugs remains on tier 3 or non-preferred. For the most current preferred drug list, prior authorization forms and pharmaceutical management procedures, visit and click on Providers & Physicians then Prescription Drugs. For a paper copy of the formulary and pharmaceutical management procedures, call

11 July/August 2009 Vol. 11, Issue 4 BLUELINK 11 CareFirst State of Maryland members are covered for the Zostavax (shingles) vaccine. As with other physician administered injectable medication and vaccines, coverage for these services is not provided through the pharmacy benefit. They are considered medical services and must be obtained and administered by the member s physician. Pharmacy benefits are only intended to cover oral medications and self-injectables. When seeing a State of Maryland member who needs the Zostavax vaccine, do not write a prescription and direct the member to a pharmacy to obtain the vaccine. Instead, arrange to obtain the vaccine from your supplier and submit a claim to CareFirst for the vaccine and administration. If your practice prefers, see the Physician Administered Injectable Medications and Vaccines article below to learn how to obtain physician administered injectable medications and vaccines by utilizing ICORE or Medmark (formerly McKesson). Since coverage for physician administered injectable medications and vaccines, such as Zostavax vaccine, is not provided through the member s pharmacy benefit (if applicable), CareFirst and CareFirst BlueChoice have contracted with ICORE HealthCare (ICORE) and Medmark (formerly McKesson) to order single doses of injectable medications and vaccines on a individual patient basis. This option includes administration supplies with every order at no additional charge, elimination of upfront cost of stocking expensive specialty injectables and coordination of the patient s coverage with direct billing to CareFirst or CareFirst BlueChoice. Your practice should continue to bill CareFirst and CareFirst BlueChoice for the administration by following CPT guidelines and using the appropriate CPT code. Orders for non-refrigerated, refrigerated and frozen medications and vaccines are shipped directly to your office typically within 48 hours. Priority overnight delivery is also available. If you have additional questions regarding the option to obtain your injectable medications and vaccines from either ICORE or Medmark, please contact your Professional Provider Relations representative, or call ICORE at or Medmark at *This information applies to commercial members only.

12 12 BLUELINK July/August 2009 Vol. 11, Issue 4 Visit us at Find Your Institutional Provider Representatives Not sure who your Institutional provider representative is or what number to call to reach him or her? See the chart below to find out. This information, as well as professional provider information, can be found in the Providers & Physicians section of by clicking on Professional or Institutional under Find My Provider Representative.

13 July/August 2009 Vol. 11, Issue 4 BLUELINK 13 Here is a list of the CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. service areas that handle Maryland and National Capital Area provider inquiries. Please copy or detach for future reference. Information that has been added or changed since this page last appeared (May/June 2009) is printed in blue font / Claims (including oral surgery): Mail Administrator, P.O. Box 14115, Lexington, Ky Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky Mental Health for Level III and Key Groups only / Claims: Mail Administrator, P.O. Box 14117, Lexington, Ky / Claims: Mail Administrator, P.O. Box 14116, Lexington, Ky Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky Provider Services Claims Submission Mail Administrator P.O. Box 14115, Lexington, Ky., Correspondence Mail Administrator P.O. Box 14114, Lexington, Ky., Northrop Grumman - NRG Prefix for claims information for benefit information Northrop Grumman - ESS or NGC Prefix All Other NASCO Accounts, including Consumer Directed Health (CDH) Plans and BlueChoice (excluding XIC prefix) Claims: Mail Administrator, P.O. Box 14115, Lexington, Ky Correspondence: Mail Administrator, P.O. Box 14114, Lexington, Ky Professional and Institutional providers in Montgomery & Prince George s counties, Washington, DC and Northern Virginia (east of Rt. 123*) Claims: Mail Administrator, P.O. Box 14113, Lexington, Ky Correspondence: Mail Admnistrator, P.O. Box 14112, Lexington, Ky *For providers west of Rt. 123, send all claims and correspondence to local plan. Professional / Institutional / Claims: Mail Administrator, P.O. Box 14113, Lexington, Ky Correspondence: Mail Administrator, P.O. Box 14111, Lexington, Ky

14 14 BLUELINK July/August 2009 Vol. 11, Issue 4 Visit us at BLUE (2583) for eligibility / Fax: / Correspondence: CareFirst BlueCross BlueShield, Mill Run Circle, P.O. Box 825, Mailstop CG-41, Owings Mills, Md / Fax: / Correspondence: CareFirst BlueCross BlueShield, Mill Run Circle, P.O. Box 825, Mailstop CG-52, Owings Mills, Md / Fax: / Correspondence: CareFirst BlueCross BlueShield, Mill Run Circle, P.O. Box 825, Mailstop CG-51, Owings Mills, Md Professional, hospital and ancillary seminar registration Authorizations 866-PRE-AUTH ( ) Fax for authorization: Case Management / Correspondence: CareFirst BlueCross BlueShield, Care Management, 1501 S. Clinton St., Mailstop CT-0816, Baltimore, Md MD Region Authorizations, eligibility and claim and benefit inquiry for PPO, MPOS, PPN and MD Indemnity / NCA Region Eligibility, claim and benefit inquiry for CareFirst BlueChoice, BluePreferred and NCA Indemnity / FEP Eligibility, claim and benefit inquiry MPOS Referrals Fax for referrals: Pharmacy benefits manager for prior authorization requests Fax: Supplier of injectable drugs Contracted vendor for CareFirst BlueChoice members Inpatient & outpatient mental health and substance abuse services Supplier of injectable drugs Emdeon GatewayEdi MedAvant (formerly ProxyMed) , ext. 813 MTrans (Misys) , ext.2188 Payerpath , ext. 2 RelayHealth Institutional Professional ProtoMed RealMed To refer patients to a program call: Asthma/COPD Diabetes and Heart Disease Oncology CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

15 July/August 2009 Vol. 11, Issue 4 BLUELINK 15 CareFirst and CareFirst BlueChoice are committed to providing quality, cost effective health care while maintaining a mutually respectful relationship with our members. The Members Rights and Responsibilities statement acknowledges our responsibilities to provide services and information to members, and outlines expectations regarding members responsibilities. The Members Rights and Responsibilities statements is provided to members in the member handbooks, published at least annually in Vitality, the member newsletter, and is available on the CareFirst Web site. You can find the Members Rights and Responsibilities statement by entering the Members & Visitors section of and choosing Rights and Responsibilities from the Solution Center. To request a paper copy, please call Eligible individuals have a right to receive information about the organization, including wellness and health promotion services provided on behalf of the employer or plan sponsors; organization staff and staff qualifications; and any contractual relationships. 2. Eligible individuals have a right to decline participation or disenroll from wellness and health promotion services offered by the organization. 3. Eligible individuals have a right to be treated courteously and respectfully by the organization s staff. 4. Eligible individuals have a right to communicate complaints to the organization and receive instructions on how to use the complaint process that includes the organization s standards of timeliness for responding to and resolving complaints and quality issues. To request a paper copy of the Members Rights and Responsibilities, call the Member Services phone number on your ID card.

16 BlueLink is published bimonthly by CareFirst BlueCross BlueShield s Corporate Communications Department. CHIEF MEDICAL OFFICER AND SR. VICE PRESIDENT OF MEDICAL AFFAIRS Jon P. Shematek M.D. EDITOR Robert Hilson newsletter.editor@carefirst.com CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc Mill Run Circle Mailstop OM1-800 Owings Mills, Maryland PRSRT STD US POSTAGE P A I D MANCHESTER, MD PERMIT No. 15 The CareFirst and CareFirst BlueChoice Quality of Care (QOC) Department investigates complaints related to the quality of care and service provided by practitioners and providers in the CareFirst and CareFirst BlueChoice networks and takes action, when appropriate. We evaluate complaints annually to identify and address opportunities for improvement across the network. What happens when we receive a complaint from a member involving a practitioner or provider? The QOC Department has only the member s perspective of the complaint and will contact you for additional information and your perception. At the conclusion of our investigation, we will advise you and the member of the findings and resolution. We are committed to resolving member complaints within 60 days, and your timely response helps us meet that goal. A practitioner may register a complaint on behalf of a member regarding the quality of care or service provided to the member by another practitioner or provider. You may submit the complaint in one of three ways: Send an to quality.care.complaints@carefirst.com Fax a written complaint to Mail a written complaint to: CareFirst BlueCross BlueShield/CareFirst BlueChoice Quality of Care Department, Central Appeals Unit PO Box Baltimore, Md Please include the following information when submitting a complaint: Your telephone number Date(s) of service Your provider number As much detail as possible Member s name about the event Member s ID number You play an important role in resolving member complaints and helping improve member satisfaction. The article titled Certain Medical Supplies Can Be Provided in a Physician s Office that appeared in the May/June 2009 issue of BlueLink was published mistakenly. The article contained several invalid HCPCS codes and in some instances did not reflect our current Medical Policies. The policy is currently being reviewed and updated, and will be included in a future issue of BlueLink. BlueLink regrets the error.